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It's time for FDA to end the tobacco epidemic

It's time for FDA to end the tobacco epidemic
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Over the past year, we have seen the consequences of letting a deadly pathogen go unchecked in too many places and among too many populations. A similar scenario has played out over decades with tobacco, which is why it remains the leading cause of preventable death in the United States, killing nearly half a million people every year. 

In the coming days, however, we can chart a new course. The U.S. Food and Drug Administration will respond by April 29 to a citizen petition urging a ban on the sale of menthol cigarettes. The agency should announce that it intends to take that step while also requiring tobacco companies to reduce the amount of nicotine in cigarettes to non-addictive levels. Together, these actions would provide a monumental victory for public health, a generational advancement in our nation’s efforts to achieve health equity, and a significant step forward to protect ourselves against future pandemics.

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Tobacco companies have developed addictive products with appealing flavors, marketed those products aggressively to maintain a regular customer base, hidden the health dangers and reaped the profits. Menthol cigarettes are perhaps the most insidious example of this business model in action. Given menthol’s propensity to mask the harshness of regular tobacco flavoring, tobacco companies rely on it to make it easier for people to start smoking and harder for them to quit. At the same time, advertising campaigns directed toward young people and people of color suggest that menthol cigarettes are healthier compared with regular cigarettes. These campaigns have been astonishingly effective. Studies show that 85 percent of African American smokers — including 7 out of 10 Black youth who smoke — use menthol cigarettes, which are largely responsible for the more than 45,000 Black lives lost annually because of tobacco use.

The Tobacco Control Act of 2009, a landmark law that provided FDA with significant new authority to regulate tobacco products, banned several characterizing flavors in cigarettes, but explicitly carved out an exception for menthol despite the science being clear on its dangers — a political decision that allowed a deadly product aimed at African Americans to continue to claim lives unjustly. Since then, the public health case for banning menthol cigarettes has only gotten stronger as we have learned even more about their connections to tobacco-related deaths and disparities. In 2011, the FDA’s Tobacco Products Scientific Advisory Committee concluded that “removal of menthol cigarettes from the marketplace would benefit public health in the United States.” Recent research finds that between 1980 and 2018, menthol cigarettes were responsible for more than 10 million additional smokers in the U.S. and hundreds of thousands of premature deaths. A study published this month finds that a menthol cigarette ban in the U.S. would help nearly one million additional smokers quit — including 230,000 Black smokers. Given this record, it is inexplicable that they remain on the market. It is long past time for the FDA to close this loophole and consign menthol cigarettes to the ash heap of history.        

Reports indicate that the FDA might pair a ban on menthol cigarettes with a significant reduction in the amount of nicotine permitted in cigarettes. Once again, there is overwhelming evidence that the public health benefits would be tremendous. While nicotine itself is not responsible for the conditions such as heart disease and cancer that are associated with tobacco use, it is the chemical that keeps people hooked to these dangerous products. Nicotine’s impact on children, including brain function and behavior, is particularly worrisome

FDA research has projected that reducing nicotine in cigarettes to non-addictive levels would spur more than 5 million people to quit smoking cigarettes within one year of implementation and 13 million people to quit smoking over five years. It would drive U.S. adult smoking rates — currently at 14 percent — to 1.4 percent by the end of the century. All told, the FDA’s report concluded that this one step would help more than 33 million people avoid becoming regular smokers and “result in more than 134 million years of life gained among the U.S. population by the year 2100.”   

The FDA initiated preliminary regulatory actions on menthol and nicotine in cigarettes several years ago, but tobacco industry pushback was relentless and the agency never followed through. We can only wonder how the COVID-19 pandemic might have played out differently had these efforts to address the tobacco epidemic not stalled. Current and former smokers are at higher risk for developing more severe illness from COVID-19. Troublingly, smoking rates among people with disabilities are twice as high as those without, putting more than one-quarter of that population — many of whom already have underlying medical conditions — at additional risk. Tobacco companies in the U.S. and across the globe have exploited the pandemic for profit. Data show that the adult smoking rates, which had been on a consistent downward trend, have plateaued during the pandemic, with cigarette sales increasing and calls to smoking cessation lines declining 

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There are additional steps we can and should take to further drive down tobacco use. Comprehensive flavored tobacco bans were passed in Massachusetts and California; other states should follow their lead. Campaigns to increase tobacco taxes hold considerable promise, particularly when revenues from such taxes are directed to prevention and cessation programs that focus on populations with the highest smoking rates; per the World Health Organization, “significant increases in excise taxes that lead to price increases have consistently proven to be the most effective, as well as the most cost-effective, mechanism for reducing tobacco consumption.” Stronger tobacco prevention laws are especially needed in states that have smoking rates which exceed the national average; a number of those states are in the South and have a higher proportion of residents who are Black, another stark example of the structural racism embedded in the operations of the tobacco industry. We must also recognize that several states do not allow their cities or counties to enact local tobacco prevention measures. These preemption laws — often passed after intense lobbying from tobacco companies — should be repealed.  

Progress at the state and local level is welcome and necessary. Even so, when it comes to achieving health equity, a national response is warranted. The FDA has the authority and the evidence base to ban menthol cigarettes and sharply reduce nicotine levels in all cigarettes. Let us hope that days from now, it also finds the will to do so. 

Richard E. Besser, a physician, is president and chief executive of the Robert Wood Johnson Foundation in Princeton, N.J. Twitter: @DrRichBesser